A.H. Exam 2 - Practice HESI Questions

The nurse is initiating an intravenous infusion of Lactated Ringer's (LR) for a client in shock recognizes that the purpose of LR for the client is to: a. Provide dextrose and nutrients to prevent cellular death. b. Increase fluid volume and urinary output. c. Draw water from the cells into the blood vessels. d. Replace electrolytes of sodium, potassium, calcium, and magnesium for cardiac stabilization. - b. Increase fluid volume and urinary output. A client has returned to the medical-surgical unit after a cardiac catheterization. What is the PRIORITY post-procedure nursing assessment for this client? a. Assess the patient's pain level. b. Observe neurologic function every 15 minutes. c. Palpate the site for a possible hematoma. d. Monitor skin warmth and turgor. - c. Palpate the site for a possible hematoma. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness.d. Examine the patient for any external bleeding. - b. Observe the patient's respiratory effort. Your otherwise healthy post-operative abdominal hysterectomy patient is noted to have a RR of 8/min. while sleeping. An ABG reveals the following: pH 7.31, pCO2 55, pO2 60. Nursing actions for this patient include all of the following except: a. placement of 02 @ 3L/min. by nasal cannula as per prn order b. administer narcotic pain medication per prn order c. stimulate patient and ask patient to take deep breaths d. notify physician - b. administer narcotic pain medication per prn order The nurse knows that a 75-year-old client with severe hypertension will experience increased workload of the heart due to which of the following? a. Increased afterload b. Increased cardiac output c. Overload of the heart d. Increased preload - a. Increased afterload Which is the most important instrument used as a diagnostic and monitoring tool for determining the severity of a shock state?a. Arterial line b. Indwelling urinary catheter c. Electrocardiogram (ECG) monitor d. Pulmonary artery catheter - d. Pulmonary artery catheter What are the appropriate nursing interventions for the patient with delirium in the ICU (select all that apply?) a. Use clocks and calendars to maintain orientation. b. Encourage round-the-clock presence of caregivers at the bedside. c. Sedate the patient with appropriate drugs to protect the patient from harmful behaviors d. Silence all alarms, reduce overhead paging, and avoid conversations around the patient. e. Identify physiologic factors that may be contributing to the patient's confusion and irritability. - a. Use clocks and calendars to maintain orientation. c. Sedate the patient with appropriate drugs to protect the patient from harmful behaviors e. Identify physiologic factors that may be contributing to the patient's confusion and irritability.